- Make the patient comfortable.
- Make the exam easy for yourself
- Don’t miss problems on the vulva.
- Expert use of the speculum.
The best results occur when the patient is physically and psychologically comfortable. The relaxed patient allows better visualization of the perineum and easier palpation of the pelvis.
Establish rapport by such methods as asking questions, smiling, expressing interest in their problems, and regret that they are not feeling well.
A full bladder will create discomfort for the patient and make your exam more difficult.
Before touching the patient, let the patient see you washing your hands.
Unpadded stirrups are uncomfortable. Make sure yours are padded.
Appropriate draping preserves patient dignity, but too much draping creates patient anxiety.
When inserting a vaginal speculum, make sure it is lubricated and the labia are protected against pulling or pinching with the speculum. When removing the speculum, see that the blades do not slam shut, pinching the vulva.
Most patients are more comfortable if the head of the bed is elevated at about a 30 degree angle.
Some patients have shorter legs, some longer. Adjust the stirrups so the patient is comfortable. The width of the stirrups is adjustable. To achieve the best visualization, find the widest positioning that is still comfortable for the patient.
Position the patient’s buttocks so they are just beyond the edge of the exam table. Without this positioning, you won’t have the full range of movement of the speculum. Have the patient slide down to this favored position. With the patient just beyond the edge, the speculum can rotate fully anterior as well as posterior. Your exam will be better and the patient more comfortable.
For the best visualization of the perineum, position your light so you are looking just over the top of it.
Carefully inspect and palpate the mons. Without this survey, it is easy to miss small lesions, such as warts or molluscum, as are shown here.
Palpable inguinal lymph nodes are common and considered normal. Markedly enlarged or tender lymph nodes can be a sign of infection, trauma, or malignancy.
Visually inspect the clitoral hood and Skene’s glands. To accomplish this, it may be necessary to retract the labial skin upward and outward. Then check both sides of the minor labia for skin lesions or masses.
Expose the vestibule and check for lesions or masses. Patients with vulvar vestibulitis will have redness and tenderness at the junction of the hymeneal tags and the vestibule. This can be confirmed with a Q-tip.
The single finger palpates first the urethra, and then the bladder. Urethral tenderness suggests urethritis…bladder tenderness suggests cystitis.
Palpate the labia majora for the presence of hernias superiorly, or Bartholin cysts inferiorly.
Speculums come in different sizes and shapes. Choose a speculum that fits your patient. Speculums typically have two adjustments. One enlarges the opening, and the other opens the speculum blades. After fully inserting the speculum, enlarge the opening diameter, and then open the blades.
Some vaginas are angled downward. Some are horizontal, and some angle anteriorly. Insert the speculum following the axis of the vagina whichever way it is oriented. Otherwise, your insertion will not be successful and the patient will be uncomfortable. If you are uncertain of the vaginal orientation, feel the direction with your index finger and then follow that path with the speculum.
Remember to keep the speculum closed until it is fully inside the vagina. Opening the speculum prematurely will usually make it more difficult to find the cervix and will likely be uncomfortable for the patient.